PUBLISHED BY ORMCO CORPORATION • VOL. 6, NO. 2, 1997

®

Dr. Turley Interviews Dr. NandaPage 2

Dr. Scott Takes a New Tack to Close SpacesPage 6

Mr. McMahan on Managed CarePage 12

Ms. Brunner on the Upbeat OfficePage 13

Dr. Clark on Marketing Plan ImplementationPage 16

CLINICALImpressions

Dr. Nanda

BiomechanicsDr. Patrick Turley Interviews Dr. Ravi Nanda

r. Turley: Ravi, biomechanics in orthodontics has taken a backseat foryears, but recently, more and more orthodontists are paying attention to it. Where do you think we are headedin this area?

Dr. Nanda: Yes, Pat, I have noticed a keeninterest in biomechanics by the ortho-dontic specialty in recent years. We aremore and more curious about how ourappliances work and what we can do to

improve them. The specialty is movingaway from technique-oriented approachesthat treat, for example, all Class II, division 1 patients with wire “X” and extraction cases with wire “Y.” Now wewant to know the “guts” of a wire, loop or a spring, such as magnitude, moments,constancy, direction of force, as well asside effects and methods to prevent andreduce them.

I have always said that we orthodontists

Dr. Ravindra Nanda currently serves asprofessor and head of the Department ofOrthodontics, University of Connecticut.He received his orthodontic training first atLucknow University, India, then from theUniversity of Nijmegen, The Netherlands,and the University of Connecticut. He alsoreceived a Ph.D. from the University ofNijmegen. Dr. Nanda has done extensiveresearch, most recently concentrating onclinical orthodontic trials and the applicationof biomechanics in a busy orthodonticpractice. He has authored and coauthoredthree orthodontic books and more than100 scientific and clinical articles in majorjournals.

Dr. Patrick K. Turley received his D.D.S.degree from UCLA and his M.S.D. degree andcertificates in both orthodontics and pediatricdentistry from the University of Washington.He currently serves at UCLA as professorand chairman of the Section of Orthodonticsand director of the postgraduate programin orthodontics, as well as the combinedorthodontic/pediatric dentistry postgraduateprogram. Dr. Turley is president of the PacificCoast Society of Orthodontists. His interestshave focused on the areas of early treat-ment (especially Class III malocclusion),treatment of traumatic injuries in childrenand the use of endosseous implants asorthodontic anchors.

2

D

often spend half our time treating patients’ problems and the other half correcting the problems we create, often due to inadequate mechanics. Such examples include loss of anchorageand faulty root inclination of incisors and posteriors. If we apply sound mechanics, side effects can be minimized,treatment time shortened, and chair timesaved, not to mention the benefits ofpeace of mind.

Since Edward Angle invented the edge-wise appliance, there have been few, ifany, revolutionary advances in mechano-therapy. Most of our progress has beenmade through improvements in and variations on bracket design and the clinical application of new wire alloys. Yet, 100 years later, we are still vexed bythe same problems as our forefathers.Anchorage control, predictable and precise results, stability and complianceare still confounding difficulties in orthodontics. Many clinicians have offered solutions by making refinementsin the appliance itself. The tremendousnumber of bracket prescriptions and orthodontic techniques advocated by the leaders in this field are evidence of our focus on the appliance. Perhaps theproblems are not in the appliance, but in our analysis of its use. Incorporatingbiomechanical concepts into everyday patient care may be where we are headedand the source of the next generation ofclinical advances.

Dr. Turley: A lot of clinicians find bio-mechanics difficult and too theoretical.Why?

Dr. Nanda: This has had a lot to do withus – educators, researchers and orthodon-tists active in the area of biomechanics.We did not describe principles and appliances in a user-friendly way. The terminology associated with learning biomechanics probably has limited theclinician’s understanding. Sometimes simple ideas seem complex because of the language and terms used. Anotherproblem is the quantitative nature of the field: the mathematics used to demonstrate the concepts often seems tointimidate the learner. But for the mostpart, the mathematics is simply based on

high-school level geometry. The more exotic analysis, such as finite elementanalysis, are used more in the engineeringof appliances than in clinical practice.This is changing fast.

One should remember that biomechanicsis not a technique. It is applicable to allthe orthodontic techniques – any wire,spring or loop which delivers a forcewhen ligated into the brackets. So a basic understanding of biomechanics isessential for all orthodontists in order tounderstand what forces we are applyingand what sequelae to expect. We wouldnot expect our internist to prescribe adrug without telling us the dosage, thefrequency and the duration of intake. In orthodontics, we apply a force on teeth with only a minimal idea of that

force, its moments or its side effects. So the first order of business for all ortho-dontists should be to take a step back andtry to understand from the standpoint ofbiomechanics what is working and whatis not working and how to fix it.

With an understanding of biomechanics,we’ll find that simple loops, cantileversand a small bend at the right place in the wire are all that is necessary to im-prove our favorite technique. Simple,sound principles of biomechanics can beapplied to any technique.

Dr. Turley: Why isn’t biomechanics a bigger part of all orthodontists’ training?

continued on following page 3

“Simple, sound principles of biomechanicscan be applied to any technique.”

Clinical examples of moments of a force. A – A mesial force at the molar bracket creates a moment tending to rotate thetooth "mesial-in." B – An expansion force on a molar creates a moment tipping thecrown bucally. C – An intrusive force at themolar bracket creates a moment tipping the crown bucally.

Third-order side effects from space closure.A – Vertical forces acting on the molar secondary to unequal moments used forGroup A space closure; the beta moment is greater than the alpha moment. An extrusive force occurs at the bracket. B – The equivalent force system at the center of resistance of the molar; the extrusive force at the bracket results in a moment rotating the molar in a crown lingual direction. C – The predicted toothmovement from this force. D – The verticalforces acting on the canine secondary tounequal moments used for Group A spaceclosure. E – The "equivalent force system"at the center of resistance of the canine;the intrusive force at the bracket resultsin a moment rotating the canine in a crownbuccal direction. F – The predicted toothmovement from this force.

D E F

A

A

B

C

B C

Illustrations from Biomechanics in Clinical Orthodontics courtesy of W.B. Saunders Company

Dr. Nanda: A good question, Pat. Our basic problem in this area has been a huge gap between the classroom and clinical practice. The students are taughtall the details of forces, moments and couples, but in the clinic, there is little application of biomechanics. Many clinical approaches follow specific wire sequences or are taught as if there are“magical” properties incorporated into thebracket. The student becomes more con-cerned with the technical aspects of careand forgets about how the appliance isworking. There is good news, however.Orthodontic departments are spendingmore time in educating their studentsabout biomechanics, and several schoolsare moving away form technique-basedapproaches to orthodontics.

I must add that we at the University ofConnecticut have contributed signifi-cantly by providing educators in variousprograms who can link biomechanics toclinical practice. Out of our 100+ gradu-ates in the last 25 years, 20 are in full-timeteaching, 20 are in part-time teaching, andfour are department heads.

Dr. Turley: What are some examples ofbiomechanically oriented appliances?

Dr. Nanda: The best example is the intrusion arch. Although the name impliesthat it only intrudes, it can simultaneously correct Class II molar relationships, especially in adolescents. The same wirewith a simple variation can close anteriorspaces, flare incisors, correct occlusalplanes or, if ligated upside down, extrudeanterior teeth. On top of that, you knowhow much force you are using, what moments you are generating and whatmeasures you have to use if you do notlike the side effects. And this appliancecan be used with any treatment approach.Actually, all appliances are biomechan-ically oriented; we just do not look atthem that way.

As several chapters in our bookBiomechanics in Clinical Orthodontics reveal, only three to four types of wire designs accomplish almost all types of

tooth movements. A given wire may lookthe same from the standpoint of its shapein the mouth, but a different placement ofa bend or loop would deliver a completelydifferent type of tooth movement.

Dr. Turley: What are the advantages of using biomechanically oriented appliances?

Dr. Nanda: The #1 advantage is that youcan go from point A to point B in astraight line. Let’s take a look at an example. In extraction patients with biomechanically oriented space closure,you can retract all six anterior teeth intothe extraction site with minimal anchor-age loss, excellent root alignment of theposterior teeth and ideal axial inclinationsof the incisors. On top of that, you onlyhave to activate the appliance once during treatment. The maximum forceyou need for space closure ranges from300 to 350 grams, and you lose only 25 to 30 grams of force with each millimeterof tooth movement. Compare this withsliding mechanics: There you have unknown force values, continual elasticchanges, uneven forces due to fast drop-off in force, force reactivation eachtime – I can go on and on.

Applying the principles of mechanics toappliance design and selection increasescreativity and innovation in solving ourpatients’ problems. How many times havewe faced the perplexing problem of one of our patients not responding well totreatment? When we are dependent on“cookbook” techniques, these problemsmay never be solved. With careful analysisfrom a biomechanical perspective, uniquesolutions may be found.

In a nutshell, biomechanics allows you todesign an appliance that will give you apredictable tooth response without guess-work.

Dr. Turley: Why should an orthodontistcare about the specifics of forces andmoments if a particular technique isclinically successful from an empiricalperspective?

Dr. Nanda: Orthodontists should careabout specifics of forces and moments.Orthodontics is little different, let’s say,from driving a car and knowing the mechanics of an automobile. In our specialty, we deliver the forces, so it becomes imperative that we must knowwhat we are doing.

I concede that 60 to 70 percent of theadolescent patients in our practices probably do not need specialized mech-anics. The problem comes with patients who have complex problems such as open bites, deep overbites, midline discrepancies, asymmetric molar occlusion, moderate to severe crowding,critical anchorage, crossbites, etc. A simple straight wire and chain elastics arenot going to solve these problems. Thesepatients need a comprehensive treatmentplan with a mechanics plan to achieve results. Use of biomechanically orientedappliances in these patients will helpachieve tooth movement compatible withsoft tissues, facial bones and jaw function.Let’s face it. No one has perfect resultsevery time. We love to show off our successes, but it’s when we come up shortthat we lose sleep. When problems arise,for instance, when our tried-and-true approaches are failing, we must developalternatives. Understanding biomechanicsand applying these principles aid ourproblem solving.

Dr. Turley: What are some examples of commonly held beliefs in clinical orthodontics that make little sensefrom a biomechanical perspective?

Dr. Nanda: Simple examples would bethe use of straight wires, step-ups andstep-downs or reverse curve of Spee wiresto correct deep bites. You often hear orthodontists say that they have intrudedthe incisors to correct the deep bite.Actually, all these wires correct the deepbite by extruding the posterior teethand/or flaring the incisors. These approaches may result in bite opening,but predictable intrusive tooth movementmay or may not occur. Unless you usespecific intrusive mechanics, it is difficult

Dr. Nandacontinued from preceding page

to achieve intrusion.

A straight wire or a flat wire placed in acrowded arch or one with a deep curve ofSpee will invariably level the teeth by theprocess of extrusion and flaring. This hasserious implications for a patient with along face, a large interlabial gap and gummy smile. The straight wire will alignteeth very well, but it will increase verticaldimension problems. This brings me backto your earlier question as to what is “clinically successful.”

Another example is the description ortho-dontists use for incisor torque. A hundredyears ago, torque was described in degrees. Now, we have been to the moonand are moving on to the next millenni-um, and we still describe incisor rootmovement in degrees. Degrees is not theway to describe force magnitude. A twistin a rectangular wire can deliver signifi-cant stress at the apex, but we still use itwithout any idea of magnitude of forceand moments.

Finally, all techniques are limited byNewton’s laws of motion, perhaps themost important being that for every actionthere is an equal and opposite reaction.This means for every distal force, theremust be a “balancing” mesial force, or vice versa. Many times tooth movementsare described without regard for the reactive forces. Distalization of molarswith intraoral anchorage may often produce a reactive mesial movement ofthe anchorage teeth. In other words, thereare no free lunches; the laws of physicsapply to all our techniques.

Dr. Turley: In the book you recentlyedited, Biomechanics in ClinicalOrthodontics, Class II treatment receives a lot of attention. Why?

Dr. Nanda: We had a symposium inConnecticut in 1993 on the correction ofClass II malocclusions and another in1995 on biomechanics. I invited speakersfrom the two symposiums to contributechapters for this book. Leaders in the fieldof biomechanics and orthodontics such as

Drs. Bantleon, Burstone, Dermant,Gianelly, Graber, Kuhlberg, Kusy,Lindauer, Melsen, Mulligan, Ram Nanda,Pancherz, Pearson, Shroff and Siatkowskihave all contributed excellent chapters tothis book. The emphasis of the book is onClass II, division 1 treatment as it relatesto biomechanics. However, the principlesdescribed in the book are applicable toevery aspect of clinical orthodontics. We have deep bite, anchorage problems,extraction and nonextraction mechanics,etc., in all types of malocclusions. Overall,

emphasis of various chapters has been tocorrect specific problems, rather than todescribe a malocclusion on the basis ofthe molar occlusion.

Dr. Turley: Can these principles be applied to Class III treatment?

Dr. Nanda: Yes, Pat, you can apply thevery same principles. As you and I havebeen active in improving methodologiesto correct skeletal Class III in grow-

continued on page 23 5Illustrations from Biomechanics in Clinical Orthodontics courtesy of W.B. Saunders Company

T-loop positioned off center for Group Aspace closure. A – The force system forGroup A space closure, with greater betamoment than alpha moment. Note that thereare vertical forces in conjunction with amoment difference. B – The length of thebeta "arm" is shorter (by about 2 mm) thanthe length of the alpha "arm." The activationof the spring is 4 mm. C – The fully insertedspring for Group A space closure.

Sequence of canine movement duringretraction with sliding mechanics. A – The normal component of force (N) and the frictional resistance to movement (f).B – The bracket tips until the diagonallyopposite corners of the bracket contact thewire. C – The wire deflects produce a coupleto upright the tooth.

A

B

Clinical examples of couples. A – Engaging awire in an angulated bracket. B – Engaging arectangular (edgewise) wire in a bracket slot.

“With an understanding of biomechanics,simple loops, cantilevers and a small bend at the right place in the wire are

all that is necessary to improve an orthodontist’s favorite technique.”

A B CMovement

A

B

C

Dr. Scott earned his D.D.S. from the University of Tennessee School of Dentistry in 1982 andhis M.S.D. in Orthodontics from Baylor College of Dentistry in 1984. He has lectured in boththe United States and abroad on the Orthos Appliance System, early treatment and facemasktherapy. He is a board-certified orthodontist with a private orthodontic practice in Longview,Texas.

6

by Michael W. Scott, D.D.S., M.S.D.Longview, Texas

n a previous issue of Clinical Impressions, I stated the list of my personal practicegoals. That list of goals has remained oneof the foundations of my practice for yearsand consists of:• Producing consistent, predictable,

high-quality orthodontic results• Practicing with great efficiency• Starting all the cases I care to start• Making a reasonable profit• Having fun

It is with the first two goals in mind that I would like to present an orthodonticproblem that, at least for me, poses atreatment planning dilemma virtuallyevery time it is encountered.

An eight-year-old patient is referred toyour office by her general dentist. The patient’s dentist is concerned that themaxillary permanent lateral incisors havenot erupted and wants your evaluation.You take a panoramic radiograph and discover that the laterals are congenitallymissing. In addition, the primary lateralincisors show significant root resorption,even though there are no succeeding permanent teeth. As you begin your explanation to the parents that “the patient is missing her maxillary lateral incisors,” before the word missing is completely off your lips, the question isposed by the parents, “What are you going to do, Doctor ?”

The answer to the question, of course, depends on myriad factors. In some cases,

the missing teeth are ultimately replacedby a removable partial denture, a fixedbridge or an implant. In other cases, it isbest to close the spaces by orthodonticallymoving the teeth.

The latter situation will be the focus ofthis article:• A patient presents with missing

maxillary permanent lateral incisors.• The primary lateral incisors are either

missing or will be extracted due to root resorption or other considerations.

• After all factors are considered, a decision is made to close the spaces by moving the permanent cuspids, bicuspids and molars mesially.

• The cuspids will be cosmetically bonded after orthodontic treatment.

The numerous factors involved in the diagnosis and treatment planning are notthe subject of this article. How one arrivedat the decision to close the spaces is immaterial to this paper.

When tooth movement is the elected procedure, there are several ways to approach it. I will describe a method that I feel greatly increases my ability toachieve the goals of consistency, pre-dictability, quality and efficiency. My expe-rience has been that mesial movement ofthe cuspids, bicuspids and molars can bea very time-consuming, unpredictable andinefficient process. A solution to thisproblem came and bit me on my backsideseveral years ago when, by chance, one of my facemask patients was seated nextto a patient with missing maxillary lateralincisors. (You know where this is going,

The Orthodontic ApplicationSystem – Still More Ammun

I

don’t you?) To make a long story short, I began to use the A.D. ProtractionFacemask™ in many cases where the treat-ment plan called for closing spaces.

The orthodontic application of orthopedicforce systems is not a new idea. One example is the use of headgear to distalizemaxillary molars. I can think of much better ways to accomplish that, i.e.,Lokar™ Molar Distalizers, but that is whatis often proposed.

Clinical Case PresentationPatient S.A. The patient presented to myoffice in March 1989. At that time she was 7 years, 6 months of age. Summerwas referred by her pediatric dentist forthe evaluation and treatment of missingmaxillary lateral incisors. Her mother wasalso concerned about a large diastema between Summer’s maxillary central incisors. Pretreatment facial and intraoralphotographs are seen in Figures 1-5. Thepretreatment panoramic radiograph is

shown in Figure 6. A summary of signifi-cant findings from diagnostic records revealed:• Balanced facial appearance in both

frontal and profile views.• End-on Class II molar relationship.• Overjet of 4 mm.• Missing maxillary permanent lateral

incisors.• Mild mandibular crowding.• Maxillary and mandibular mid-

continued on following page 7

on of an Orthopedic Forceunition for Your Operatory!

Figure 1. Figure 3.Figure 2.

Figure 4. Figure 6.Figure 5.

Case Presentation: Patient S.A., female, 7 years, 6 months of age, congenitally missing upper laterals.

Figures 1-6. Pretreatment photographs and panoramic radiograph. Phase 1 treat-ment initiated in May 1989 and completed in May 1990.

lines were coincidental.• Skeletal Class II. ANB = 6°,

NA - APo = 9°.• Maxillary midline diastema.• Roots of the maxillary primary lateral

incisors were resorbing.

The principle concern was the long-term management of the missing lateralincisors. Summer and her mother wereboth very hesitant about placing implantsor bridgework in her mouth. Secondaryconcerns were the crowding of themandibular anterior teeth and the maxil-lary midline diastema.

The diagnostic data, along with the concerns of the patient and parent, led tothe decision to close the lateral incisorspaces over the course of time. A phase ofearly treatment would be undertaken toaddress the mandibular crowding and the maxillary midline diastema. Phase 1treatment consisted of the following:• Maxillary 2 x 2 to close the diastema

and align the central incisors cosmetically.

• Lip bumper to relieve the mild mandibular crowding.

• Mandibular lingual arch after lip bumper.

• Selective extraction of primary teeth over time.

• Bonded lingual retainer for upper 1-1 posttreatment.

•The skeletal Class II and overjet were notaddressed in Phase 1. No headgearwas used because of the decision to

move the maxillary posterior teeth mesially as time passed.

Phase 1 treatment was initiated in May1989 and completed in May 1990.Summer was then seen every four monthsto monitor the integrity of her lingualarch. The lingual arch was removed inJuly 1991, upon the eruption of themandibular cuspids.

Facial and intraoral photos taken inOctober 1991 are seen in Figures 7-11. A progress panoramic radiograph taken atthe same time is shown in Figure 12. Note

the favorable eruption pathway of themaxillary cuspids. Evaluation of thepanoramic radiograph led to the decisionto have the maxillary right and left primary laterals, cuspids and 1st molars(upper B’s, C’s, and D’s ) removed.Summer was then seen every six monthsfor observation.

In January 1994, progress records wereobtained and Phase 2 treatment was ad-vised. A summary of significant findingsincluded:• Age: 12 years, 4 months.• Missing maxillary lateral incisors

(no divine intervention occurred).• End-on Class II molar relationship.• Overjet of 3 mm.• Maxillary 1st bicuspids rotated

mesially 45°.• Maxillary and mandibular midlines

coincidental.

• Skeletal Class I. ANB = 3°, NA - APo = 4°.

• Space excess in the maxillary arch of 10 mm.

The panoramic radiograph taken January1994 is seen in Figure 13.

The Phase 2 treatment plan was as follows:• Band/bond the maxillary arch.• Bond the maxillary cuspid brackets in a

position slightly more distal than normal to help rotate the teeth into more favorable positions for future cosmetic bonding.

• Bond the maxillary cuspid brackets upside down (Figure 14) to produce more favorable lingual root torque, because these teeth would ultimately be made to resemble laterals.

• On an .016 S.S. upper archwire, use sliding hooks distal to the cuspids and begin elastic traction from the sliding hooks to a facemask (Figure 15).

• Once the cuspids are forward, position the hooks distal to the 2nd bicuspids and slide both the 1st and 2nd bicus-pids mesially at one time (Figure 16).

• The .016 S.S. archwire would be constructed with omega loops and be tied back to the 1st molars.

• Band/bond mandibular arch soon after facemask started.

• Class III elastics if needed.• Cosmetic bonding of the maxillary

cuspids posttreatment.

Cuspid brackets as opposed to lateralbrackets were used on the cuspids simplybecause of the better fit.

Summer was instructed to wear her face-mask 12 hours per day. Ormco Ram (1/4inch, 6 oz.) or Impala (3/16 inch, 6 oz.)elastics were used for traction, one oneach side. The facemask was adapted tothe patient exactly as it would be used inmaxillary protraction. (Please refer to myarticles in Clinical Impressions, Vol. 2, No.1, 1993, and Vol. 2, No. 4, 1993.) Theonly exception is the direction of pull ofthe elastics. Instead of pulling downward

8 continued on page 11

Dr. Scottcontinued from preceding page

“The use of the facemask helped to close a 10 mm space

excess in the maxillary arch that would have otherwise

posed significant mechanicalchallenges.”

Figure 7.

Figures 7-12. Photographs and progress panoramic radiograph taken in October 1991.Evaluation led to the decision to remove upper B's, C's and D's, after which patient was seenevery 6 months for observation.

Figure 9.Figure 8.

Figure 10. Figure 12.Figure 11.

Figure 13.

Figure 16 (right). After cuspids were movedforward, hooks were placed distal to 2ndbicuspids to slide both 1st and 2nd bicus-pids mesially at one time.

Figure 15. Sliding hooks distal to cuspidsused for elastic traction to facemask.

Figure 14. Maxillary cuspid brackets bondedupside down to produce more favorable lingual root torque. Note that the "dot"(usually positioned distally and gingivally) is positioned mesially and occlusally.

Figures 14-16. Phase 2 treatment plan included:Figure 13. Panoramic radio-graph taken in January 1994.

Figure 17. Figure 19.Figure 18.

Figure 20. Figure 22.Figure 21.

Figure 23. Figure 24.

Figure 25. Figure 27.Figure 26.

Figures 17-19. Intraoral progress photographs taken in May 1996, 20 months into Phase 2 treatment.

Figures 20-22. Posttreatment photographs taken in November 1996 prior to cosmetic bonding.

Figures 23-27. Final photographs taken inJanuary 1997 after cosmeticbonding.

at a 45° angle, as in maxillary protraction,the direction of pull should follow theplane of occlusion.

Once the maxillary cuspids and bicuspidswere forward, the maxillary 1st molarshad to be moved. This was accomplishedby wearing Class III elastics (Ormco Ram)from an .016 x .025 S.S. mandibular arch-wire to an .016 S.S. maxillary archwirewithout omega loops. The maxillary 2ndmolars were not banded and followed verynicely.

Progress intraoral photographs taken 20months into treatment are shown inFigures 17-19. Note the buttons placedon the lingual of the upper 2nd bicuspids.These were used along with power chainto maintain rotational control of the bicus-pids as they were moved mesially.

Treatment proceeded well with the excep-tion of six missed or canceled appoint-ments over the course of treatment. Threeof the missed appointments occurred inthe first year of treatment and accountedfor 25 weeks of excess time between visits. That might not be that critical in today’s world of 35°C Copper Ni-Ti™

archwires. However, when you are in the1994 world of braided D-Rect®, it makes a huge difference! The other three missedappointments accounted for nine weeks ofexcess time between visits.

Summer’s treatment summary is as follows:

• Total treatment time = 29 months.• Total number of visits to complete

treatment = 19.• Total time wearing facemask =

5 months.• Total time wearing Class III elastics =

4 months.

Due to the explosion in archwire technol-ogy, the archwire sequence I used is notrelevant. It is amazing how much haschanged in less than three years. Intraoralphotographs taken posttreatment areshown in Figures 20-22. These photo-graphs were taken prior to cosmetic

bonding. Final facial and intraoral pho-tographs taken after cosmetic bonding areshown in Figures 23-27.

ConclusionAs can be seen in the previous clinical example, the use of the A.D. ProtractionFacemask as an orthodontic force deliverysystem can be a valuable tool in specificsituations such as the one described. Inconsidering how the use of this force system has impacted my practice goals, I have reached several conclusions. Theresults that can be expected from the useof this force system are predictable andconsistent. The quality of the final resultachieved in Summer’s case was greatly improved by the fact that she was sparedthe need for major posttreatment restora-tive work. I feel that I delivered extremely

high-quality orthodontic care to a 12-year-old patient by providing her withthe ability to go through life with an occlusion composed of all natural denti-tion. The use of the facemask helped toclose a 10 mm space excess in the maxil-lary arch that would have otherwise posedsignificant mechanical challenges. Thiswas also accomplished very efficiently inthat the facemask was only worn for fivemonths. This efficiency of mechanics resulted in the case being more profitable.Only 19 appointments were needed tocomplete treatment.

As you consider the treatment and resultsachieved in this case, I hope you willagree that the orthodontic application oforthopedic force systems truly adds moreammunition to your operatory!

The A.D. ProtractionFacemask –Designed withPatient Compliancein MindThe A.D. (Adjustable Dynamic)Protraction Facemask™ provides dynam-ic movement in the forehead rest whileallowing the chin cup to slide verticallyalong the main frame. This means maxi-mum patient comfort while sleeping,talking or any time the jaw is moving.Since the movement of the softly paddedchin cup and forehead rest involvesmuch less sliding contact with tissue, irritation is reduced and comfort is improved. Increased patient complianceequates to more efficient orthopedic andorthodontic therapy.

The A.D. Protraction Facemask is fullyadjustable, so one size fits all patients.The horizontal arm for elastic hookupcan also be positioned inside or outsidethe vertical bar to modify forces and vectors. In addition to the standard facemask design, a modification is nowavailable for the Asian patient. The Asian

Profile Protraction Facemask has a moreflattened forehead rest, a flatter andbroader chin cup and less curvature inthe vertical bar profile. Some orthodon-tists prefer the new design for their non-Asian patients as well. Both typesare available as a complete package containing a choice of blue or lavendermasks, three chin and three forehead replacement pads and a hex key for adjustments. Order information is pro-vided on page H of the Center Section.

Dr. Scottcontinued from page 8

11

by Wayne McMahanMontgomery, Alabama

couple of years ago, Dr. Marvin Zatts, a dentalconsultant for ThePrudential InsuranceCompany, and I made separate presentations to the Middle Atlantic Societyof Orthodontists in

Wilmington, Delaware. Later in the day,Dr. Zatts and I served on the same panel.At one point during the panel discussion,Dr. Zatts abruptly stopped defending all

dental managed care plans and gave someadvice to his audience. Dr. Zatts said,“The way for dentists to respond to badmanaged care plans is simply not to signup for them.” When I had a chance to respond, I observed that Dr. Zatts’ “don’tsign up” proclamation was one of the bestarguments I had heard in defense of theAlabama Patient Choice Law (APCL).

In essence, the APCL allows individuals in managed care plans to seek care fromany provider they choose, even if theprovider is not under contract with thepatient’s health plan. If the noncontractprovider’s fees are higher than the contractallowance, then the patient, not the plan,is required to pay the difference. The contract payment allowance can be assigned by the patient to the noncontractprovider.

How does Dr. Zatts’ “don’t sign up” advicesubstantiate the need for the APCL?Obviously, dentists have the option of notsigning up for managed care plans thatthey feel are, in Dr. Zatts’ words, “badplans.” But what about the patient who isan employee of company XYZ? Rarely areemployees allowed any input into the selection of their company’s health plans.So what is the employee’s option if thecompany plan is a bad one? Without alaw like the APCL, there is obviously nooption. The dentist may elect to eschew“bad plans,” but the employee must acquiesce to the employer’s decision orpay for care out of his or her own pocket.

When the APCL legislation was beingconsidered in 1994, lobbyists for BlueCross and Blue Shield of Alabama (BCBSA) told legislators that the passageof the APCL would result in the demise ofmanaged care in Alabama. Legislators didnot buy BCBSA’s arguments, and the bill

was eventually passed by an overwhelm-ing majority of both the House and Senateand signed into law by then Governor Jim Folsom, Jr.

BCBSA’s next step was to file suit inFederal District Court seeking to have the APCL overturned. The BCBSA challenge to the APCL was assigned toFederal District Judge Seybourn Lynne.Due in part to some serious health problems that Judge Lynne experiencedshortly after the lawsuit was filed, theBirmingham Federal Judge did not issue his ruling in the case until January of last year. The decision was in favor of BCBSA.

Although the defendants (seeking to uphold the APCL) in the suit immediatelydetermined that Judge Lynne’s orderwould be appealed to the EleventhCircuit, the formal filing of the appealproved to be a legal marathon. It now appears that a three-judge panel of theEleventh Circuit will hear oral argumentsregarding the APCL in either spring or early summer of this year. In additionto the briefs already submitted to theEleventh Circuit by the attorneys representing the defendants, both theAmerican and New Jersey dental associa-tions have submitted written argumentssupporting the defendants’ position.

The case before the Eleventh Circuit involves a number of complex legal issues. In essence, however, the court willreview two facets of Judge Lynne’s earlierdecision: first, that ERISA (self-insured)plans are preempted or exempt from complying with the APCL and, second,that the APCL is not applicable to anyBCBSA plans.

Wayne McMahan has been the executivedirector of the Alabama Dental Associationfor the past 17 years. Prior to his currentposition, he worked for eight years as theexecutive secretary to a former governor andlieutenant governor of the state of Alabama.Mr. McMahan is also currently serving as thepresident of the American Society ofConstituent Dental Executives. He residesin Montgomery, Alabama, with his wife and

two children.

Perspective on Dental Managed Care Plans

The Solution: “Don’t sign up!”

12

A

continued on page 22

by Barbara Brunner, M.A.Orange, California

ustin Hoffman, Robert De Niro, MerylStreep, Susan Sarandon, Harrison Ford,James Earl Jones. Actors and actressesrenowned for creating signature roles. But no director ever sent any of them before a camera with only inspiration andan abstract concept of how they were todevelop their dialogue. They got a script.

Choirs sing from hymnals. Orchestrasplay from scores. Presidents speak fromnotes. They plan. They practice.

They practice. They practice. They prac-tice.

Yet every day doctors send unseasonedstaff members to represent them and theiroffices before the moms and dads, theyoungsters and the teens of the worldwith only the most vague idea about howto translate their vision of quality patientcare into day-to-day conversations and instructions. “We’re a patient-oriented office, Mary Ann. You’ll find that we dowhatever it takes to make sure that ourpatients are happy to come here and aresatisfied with their smiles when theyleave.” Some staff members are naturals,keen at transforming such abstract ideasinto dialogue, picking up specific wordingfrom you and other talented staffers. Theyare the peak performers. Others, at best,simply muddle by.

You usually find out about the worst muddlings inadvertently, perhaps whenyou overhear a particularly jarring verbalblunder, when repeated misunderstand-ings occur or when your best referringdentist relates an appalling comment oneof your staff members made to a mutualpatient.

Each staff member represents you andyour practice in each and every inter-action with a patient. With patient service being so inextricably tied to theperception of your clinical care, it seemscuriously uncharacteristic of you (whofusses over tooth movement measured infractions of millimeters) to leave criticalcommunications to happenstance. One alternative is scripting.

Make Sure We’re All Readingfrom the Same Sheet of MusicScripts are working documents, not meantto have everyone marching in lockstep,but flexible models that provide keywords and, more importantly, keyphilosophies about how to deliver specificmessages or answer critical questions.Like mission statements, much of the value in developing scripts is the discus-sion that goes into them. Such discussionencourages buy-in from your staff. It alsohelps them internalize your philosophiesby getting a clear understanding of the importance of key phrasings. With scripts,you and your staff will weave your individual brands of humor (“Retainersare pajamas for your teeth”) and yourchairside charm (“So, Christy [age 12],

Just Say It!Creating the Upbeat Office

Ms. Brunner is manager of Ormco’s PracticeDevelopment Seminar Series. She holdsa master's degree in organizationalcommunication and management fromOhio University. With 20 years’ experience incommunication and marketing, Ms. Brunnerhas led two companies in transitioningto a culture where increased involvementin decision making at all levels resulted inoverachievement of stringent goals. WithOrmco, Ms. Brunner has been instrumentalin translating skill requirements of doctorsand staff members into educational policyand practice.

13

Dcontinued on following page

did you come with your husband today?”)with proven patient relations techniques.When they become second nature, youcan just say it and know that the wordingyou’ve shaped will support and clarify themessage you purposely mean to deliver.

Your Relationship is ShowingThere are at least two aspects to everycommunication: the content and the relationship. The relationship betweenpeople colors every aspect of the content.It’s why a good friend can say somethingrude and you chalk it up to a bad day. It’s why a person whom you distrust cangive you a compliment and you wonderwhat they want. We often convey how we feel about someone through how weshape the content.

Every interaction should have the sameobjective: to have the patient clearly understand the content and have the relationship aspect continuously be saying, “You’re worthwhile. We care.”

While most of us have these inten-tions, we have often picked up our

habits of phrasing early in life. We maywish to espouse important values of being patient-centered, partnership-oriented, caring and positive in our outlook. Our language can often still connote myopia, condescension, controland even cynicism. Communication when handling persistent noncomplianceissues should certainly be progressive,with greater brevity and more directnessas discussion continues. First, however,let’s look at ways we can inject consistencybetween our philosophies and our language before the conversation needs to escalate.

No Buts About ItEver been given a compliment only tohave it taken away in the same breath?“Hey, Doc, nice job, but that space between these two back teeth always collects food.” What message did youhear? Certainly not the compliment.

A staff member is doing a particularlygood job in one area. We’d like the approach modified for a particular aspectof the job, so we say something like this:“Cindy, I like the way you’re giving thetour, but I wish you’d give more emphasisto the sterilization area.” What does thestaff member hear? Certainly not the compliment. She hears nothing exceptwhat is said after the but.

Why do we sandwich a but between acompliment and a criticism? Who knows?(Maybe we picked up the idea fromBlanchard’s One Minute Manager.) It’s askill. We learned it. We can unlearn it. If you truly want to compliment an individual, do so without the but. If thecompliment is a well deserved one aboutimportant accomplishments and the constructive criticism is a trifling thing,you end up sounding picky. If someone is doing a good job in one area except for certain aspects, build on successes tochange behavior in another way.

Compare: “David, you’re doing a great jobwearing your elastics. That means youmight get your braces off sooner, but yourbrushing hasn’t been very good. You’re

missing a lot of areas between the bracketsand your gums.” With: “David, you’redoing a great job wearing your elastics. It means you might get your braces offsooner. Won’t that be super? Being aWorld Class Elastics Wearer, I know youcan handle brushing with braces – gettingbetween the brackets and the gums. Let’shave Jenny give you some tips on becom-ing a World Class Tooth Brusher, too.”

Jenny then follows up the discussion with:“You know, David, if you’ve got elasticsdown pat, you've done the really hardpart. Now you can focus on a couple oftricky areas that your toothbrush seems tomiss. Easy stuff for the Master of Elastics.”

Compare: “Jenny, you’ve really impressedme with having picked up so many essen-tial chairside assisting skills in the shorttime you’ve been here, but I’d like to seemore detail in your treatment cards.”With: “Jenny, you’ve really impressed mewith having picked up so many essentialchairside assisting skills in the short timeyou’ve been here. Way to go! You knowwhat I’d like your next challenge to be?Detail with treatment cards. Let me getMarcy to review with you what’s expectedand why, so that by this time next week,you’ll have mastered that as well.” Notonly have we built on Jenny’s successes tochallenge her to the next level, we’ve alsomade our language more specific, makingour expectations clear with a goal and atime frame.

Note: If you have a persistent performanceissue, keep the message clean. Mixingmessages about substandard performancewith a compliment is misleading and unfair to your staff.

Patient Focus Starts with YouWhen you deliver a message from the perspective of listeners (e.g., McDonald’sslogan, “You deserve a break today.”), you help yourself see things from theirvantage point. You will more likely, then,deliver the message with a patient-centered or staff-centered focus, reinforc-ing the emphasis on meeting their needs.Introductory patient letters and14

Just Say It!continued from page 13

“Restatingproblems in

terms of challenges andopportunities

with a solutionapproach

encouragespartnership

in care.”

brochures, for example, are peppered withwe, our, I and my staff and I (e.g.,“We arepleased to have the opportunity to explainthe benefits of orthodontics,” or “We appreciate the trust you have shown byselecting us to help with your orthodonticneeds.”). Anytime you can replace thesepronouns with you, do so (e.g.,“Your initial visit is a time for us to get to knowyou and what you want to accomplish,” or “Your decision to take advantage of the benefits of orthodontics is an investment in your child’s future.”). The you perspective helps focus on the patient’s needs and can often keep youfrom spouting platitudes. Work the you perspective into your case presenta-tion verbiage. It’s a good way to differenti-ate yourself. And it’s a theme that workswith staff, too.

Note: Want to try an interesting exercise?Have everyone refrain from using thewords I or we for ten minutes at your next staff meeting. It provides insight into the paradigm within which we all operate.

Pose Problems as Challengesto Focus on SolutionsProblems point out what’s wrong.Challenges position issues in terms ofwhat can be done. Restating problems interms of challenges and opportunitieswith a solution approach encourages partnership in care.

Compare: “Mrs. Jacobs, I’ve got a problemwith David’s poor elastic wear. He’s notprogressing as quickly as he should, and I know he’s going to be frustrated if we can’t take his braces off when weoriginally planned. He just needs to understand how critical wearing his elastics is to his progress.” Here the doctor owns the problem, is focused on attitude (understand) rather than behavior and has expended considerablebreath without yet being directed toward a solution. With: “Mrs. Jacobs, we’ve got a challenge to help David improve hiselastic wear so he’ll be able to get hisbraces off when planned. David men-tioned that he forgets to put his rubber

bands back on after lunch. Is there someway we can help him remember – maybeby packing these Ormco Z-pak elastics in his lunch box? Or maybe he could wear his elastics on his little finger whilehe’s eating? Think either of these ideascould help? Or maybe you have anothersuggestion?” Now the discussion is oriented away from the problem and toward the challenge of finding possiblesolutions, focused on behavior rather than attitude and on shared ownership ofthe challenge.

What’s in It for Me?Translating features into benefits. It’s a primary tenet of every case presentationand marketing course given. If the patientis still asking “So what?” after you’vebragged about some aspect of your practice, you may still be focusing on afeature, assuming that your patients cantranslate features into benefits on their own. Don’t leave this to chance.

Feature: “We use the most advanced wiretechnology available.”

Benefit: “Because we use the most advanced wire technology on the markettoday, appointment times can often bescheduled eight to ten weeks apart ratherthan monthly as we did only a couple ofyears ago. This means less time away fromschool for Kristin and from work for you.And then there’s the comfort. These newwires move with so little force to do thesame job as traditional stainless steel wiresthat Kristin should be quite comfortablethroughout treatment.”

How You Get StartedPsychologists tell us that it takes 21 daysto develop a new skill. If changing yourteam’s language is something you consider worthwhile, work in increments.Choose one script or one general language change on which to work.Concentrate on that change for threeweeks or until you feel comfortable with it, then move on to another change.Make a game of it. Every time someoneworks creatively to eliminate an unneces-sary but, ante up $1 for pizza.

Tact is the Language ofStrengthAlmost every time we open our mouths to speak, we are attempting to influenceanother human being. These languageskills are centered around tact. Tact is thelanguage of strength. Exhibiting tact requires that you continually monitorwhat you are about to say, given your listener’s perspective and your relationshipwith that listener. It’s the art of making apoint without making an enemy. As ZigZiglar aptly puts it, “It’s difficult to offendpeople and influence them at thesame time.” 15

Scripts: Ten EasySteps to Power Talk1. Brainstorm to identify every situation

where communications are critical (e.g., recurring patient “compliance” discussions, your most unpopular policies, situations in which you know you tend to preach rather than partner).

2. Prioritize the top three. 3. Brainstorm all the ideas you already

use (not judging them at this point). 4. Develop one or two scripts for each

situation. 5. Check your phrasing against the do’s

and don’ts listed here, using other techniques you know work well.

6. Rephrase where appropriate. 7. Role play using the script, putting the

expressions into your own manner of speaking, adding humor.

8. Incorporate one script every three to four weeks.

9. Share results and alter where necessary.

10. Choose the next three priorities and repeat the process.

Just Say It! is a course offered throughOrmco’s 1997 Practice DevelopmentSeminar Series that Ms. Brunner will conduct in Minneapolis, Minnesota, June 20, 1997, and Vancouver, BritishColumbia, August 29, 1997. For more information about this course, contactyour local Ormco representative or anOrmco customer service representative at (800) 854-1741, Ext. 7001.

by Jerry R. Clark, D.D.S., M.S.Greensboro, North Carolina

n the previous article*, we discussed theimportance of getting all your practice’ssystems in place prior to initiating the development of a marketing plan. Thisprocess is essential to providing such awonderful experience for your patientsthat they will want to tell everyone theyknow about your practice. Only after allthe appropriate systems have been estab-lished is it time to aggressively market thepractice, to develop a strategy to increasethe number of individuals who will demand your service. The plan, whichwill be outlined, is similar to the sophisti-cated marketing plans used by major corporations like McDonald’s. You, too,can attract more customers just like theydo and do it in a manner consistent withthe highest levels of ethics and profession-alism. There are three basic steps in developing the actual marketing plan:• PositioningPositioning (differentiation) involves theanalysis of the determining factors, or as they are called in the marketing field, “influencing conditions,” which causeconsumers to choose one product or service over another.• DevelopmentDevelopment of the marketing plan involves using those influencing condi-tions to develop goals and strategies toreach and attract patients through the use of specific internal and external marketing efforts.• ImplementationImplementation of the plan involves theestablishment of a marketing calendar and a budget for the marketing efforts.Staff members and the doctor are assignedspecific responsibilities to make sure themarketing strategies are carried out asplanned.

Positioning (Differentiation)The decision of a consumer to choose one product or service over another is acomplicated issue. However, that process

or those influencing conditions can be analyzed by using statistical research toprovide the doctor a much better grasp of why people might choose his or herpractice. This involves:• Practice Analysis• Geographic Analysis• Competitive Environment Evaluation

From this analysis, conclusions are drawnand strategies developed to maximize theeffectiveness of the plan and to allow theplan to be implemented in a cost effectivemanner. We will illustrate this process bydeveloping an actual plan compiled for apractice by Orthodontic ManagementGroup to show how the information gathered is used to mold and develop theplan. To be effective, accurate statisticaldata must be obtained and appropriatemarket research must be performed. Theeventual marketing plan will be no betterthan the research information obtained, so take the time to do your research care-fully; otherwise, you are probably wastingyour time.

Practice AnalysisEvaluate the practice by thoroughly ana-lyzing all aspects of the practice andbenchmarking the practice at one point intime. These include the following:

Statistical Analysis – Involves the tracking of meaningful information aboutthe practice over a period of time sotrends can be determined and under-stood. See Figure 1 for an actual statisticalanalysis of a practice.• New-Patient Growth – The number ofnew patients is growing nicely and indi-cates a positive trend.• Seasonality – The practice reaches itspeak season during June, July and August.People usually are not interested in spend-ing money on orthodontics in December.• Start Rate – There is a dramatic rise inpatients getting ready to start treatment.This is an extremely favorable trend.

Conclusions: Continue to increase the

Dr. Jerry R. Clark is a board-certified ortho-dontist with a practice in Greensboro, NorthCarolina. He is also CEO of OrthodonticManagement Group, Inc. (800-621-4664),a consulting firm specializing in increasingthe profitability and productivity of ortho-dontic practices. Services include develop-ment of strategic business plans, budgetingand marketing plan implementation, doctorand staff training, tracking services, practicevaluation, partner location services and

practice transition facilitation.

16

Developing and Implemen

I

*See article by Dr. Jerry Clark, “Developing an Effective Marketing Plan for Your Practice,” Clinical Impressions, Vol. 6, No. 1, 1997

number of new patients by implementinga strong marketing plan. Do not concen-trate on external marketing during thesummer months or December. Investigatethe new-patient exam and recall proce-dures and discuss any improvementswhich can be made.

Procedural – Based on the statistical information, many procedures which arealready in place seem to be working well.However, some improvements can bemade.

Conclusions: To improve current new-patient procedures:• Make the new-patient “experience”

more comprehensive and informative (minimum 30-minute exposure).

• Ask the new patient his or her primary concern and focus on it.

• Inform new patients of sterilization procedures.

• Give a thorough office tour before the new-patient exam.

To improve the consultation:• Shorten consultation and make it more

relevant to the patient.• Begin the consultation by addressing the

patient’s concerns.• Use visuals – photographs, models,

imaging.• Provide the patient with a vision of

completed treatment.

Image – What image does the practicepresent to potential patients? What is their perception of the office, doctor and staffmembers? How does the community viewthe practice? These are all assessed andevaluated.

Internal• Physical facility – Has been completely

remodeled and redecorated; grounds, parking lot and signage are very good.

• Staff appearance – Excellent, profession-al; uniforms project an unspoken unity among staff members.

• Doctor’s appearance – Excellent, pro-

fessional; projects warm, caring attitude.• Office atmosphere – Excellent and

professional, yet light, friendly, warm and caring.

External• Correspondence – Excellent; all

brochures, letters and correspondence are professional in appearance and comprehensive, yet brief; everything is coordinated and is highlighted by an attractive, professional, distinctive logo.

• Positive outside perceptions – Very positive, good treatment, competent, friendly staff, patients seen on time, a fun place for patients to be treated.

• Negative outside perceptions – Too expensive, doctor is often out of the office, doctor is perceived to be too tough on patients and parents for noncompliance.

Conclusions: Concentrate on changing theoutside perceptions of the practice fromnegative to positive. Address each issue ina strategic manner.• Too expensive – Convey to patients at

the new-patient appointment that

orthodontics is expensive. However, it is the responsibility of the practice to make sure that treatment is affordable and will be made so through flexible financial arrangements. Flexible arrangements should be provided only to those individuals who have demon-strated financial responsibility in the past, i.e., good credit rating. If the rating is good, provide sufficient options for payment to facilitate treatment accep-tance.

• Doctor is often out of office – Doctor needs to inform staff of exact plans, and staff conveys to patients that the doctor is out of the office for legitimate reasons. Example – “Doctor is attending a continuing education seminar. He is constantly going to programs to allow him to keep abreast of all the latest developments in orthodontics.”

• Doctor is too tough on patients and parents for noncompliance – In the future, the doctor will only give positive feedback and leave it to the staff to discuss compliance issues. The staff will

17

enting the Marketing PlanStatistical Analysis

1992 1993New Diagnostic New Diagnostic

Patients Records Patients RecordsJanuary 28 16 24 15February 29 15 26 21March 27 19 27 18April 27 18 20 18May 23 17 21 20June 32 24 27 23July 31 17 47 29August 28 13 34 31September 27 18 24 10October 20 20 31 30November 22 11 34 20December 21 7 18 14

TOTAL 315 195 333 249Start Rate 62% 75%

Figure 1

Continued on following page

discuss hygiene and noncompliance with patients/parents and keep the doctor out of the “fray.” If treatment is being extended due to noncompliance, the treatment coordinator will discuss, well in advance, the potential for increased charges or early appliance removal before treatment completion.

Current Referral Status – See Figure 2for an example of patient referrals to apractice. From this information, importantconclusions can be drawn that will guideyou in the formulation of the strategy formarketing to referring doctors.

No. patients Percent referred of total

into practice referrals

Doctor referrals 174 47Friend/family referrals 128 35Previous orthodontist 15 4Other 53 14Total 370 100

One hundred thirty referrals came from 16doctors while the other 35 doctors referredonly 44 patients. Seventy-five percent ofthe doctor referrals came from approxi-mately 30 percent of the doctors.

Conclusions: The referring doctors shouldbe divided into two tiers.• Tier 1: The 16 doctors providing the

largest percentage of referrals. The prac-tice should also choose five doctors not in the current Tier 1 level and concen-trate on bringing them into Tier 1 over the next year. Market this group aggressively.

• Tier 2: The doctors who only occasion- ally refer to the practice. Should receive only minimal marketing efforts at little or no expense to the practice.

Current Patient Base –• Adults, 33 percent• Children, 67 percentPractice should concentrate on fulfillingthe wants and needs of both patient bases.

Adult• Needs: orthodontic treatment, affordable

treatment.• Wants: constant information on what is 18

Dr. Clarkcontinued from page 17

Current Referral StatusNo. of No. of No. of

Doctor referrals Doctor referrals Doctor referralsAnderson 4 Herbin 1 North 1Best 2 Hewitt 2 Orr 1Blair 4 Hicks 3 Owens 17Blaylock 1 Hill 4 Parker 1Boles 6 Jolly 4 Rabb 1Campbell 1 Jones 1 Redding 1Capps 1 Kiser 1 Riley 3Cecil 15 Kramer 1 Sharp 2Chandler 2 Lee 2 Smith 1Church 19 Lewis 2 Snead 1Costello 3 Lind 1 Taylor 1Douglas 1 Lockhart 1 Watkins 1Earl 1 Lowry 1 White 1Fowler 4 McNair 6 Wilson 8Fox 1 Meyer 1 Zales 19Garrett 11 Mobley 1 Fr/Fam 128Harper 2 Moss 1 PrevOr 15Henson 1 Noble 3 Other 53

Figure 2

Financial Policy and OptionsIn an effort to help you in budgeting the financial portion of your orthodontic investment, we have organized several payment options:

• Option 1 – Ten percent off total fee for cash payment at the start of treatment• Option 2 – Seven percent off total fee for full payment within 90 days from the start of

treatment, divided into three equal payments• Option 3 – Twelve equal monthly payments with no down payment for full treatment; six

equal monthly payments with no down payment for Phase 1 and partial treatment• Option 4 – Twenty-five percent down and 18 months to pay for full treatment; 25 percent

down and 12 months to pay for Phase 1 treatment• Option 5 – Ortho-Line financing with zero down and long-term payment of a minimum of

3 percent of the balance

NOTE: As in any financial arrangement, credit history may influence final arrangements. Extension of payments beyond 18 months may bepossible with the addition of a small bookkeeping fee. It is our goal tomaintain excellent financial relationships with our patients. The #1 reason for unhappy patients is unclear or unkempt financial arrange-ments.

Figure 3

happening to them; communication on progress toward completion; encourage-ment; “don’t waste my time;” want to know you care.

Children• Needs: orthodontic treatment.• Wants: to have fun; “How much

longer?” (information); encouragement (compliance).

Conclusions: Provide ongoing informationand encouragement about treatment andtreatment progress that does not back the doctor into a corner of promising theexact time treatment will be completed.Make sure children have fun every timethey come in for an appointment.

Fees and Financial Arrangements –Fees must be fair for both the patient andthe doctor. The entire patient experiencemust be one of excellence, not just thetreatment being performed. After all,aren’t the beds at Ritz-Carlton the same asthe beds at Days Inn? The difference inwhat these two companies charge for anight’s stay has nothing to do with whyyou are staying there (the bed) but every-thing to do with the experience (customerservice and quality of the facility).

Conclusions: Establish your fee structureaccording to the experience, not just thetreatment. Financial arrangements mustbe made affordable for patients to accepttreatment. Several specific payment options should be presented to allow thepatient to choose the most suitable. Anexample of financialoptions can be foundin Figure 3. The doctor must also determine the prac-tice’s discount policy.Are any individualsoffered treatment atreduced fees? Clergy?Physicians? Dentists?Staff? This policymust be establishedand discounts givenonly to those predeter-mined to be eligible.

Current Marketing Plan – Figure 4 illustrates a marketing plan previouslyused by a practice.

Conclusions: Many marketing approachesare currently being directed toward patients and referring doctors. Ensurethey are organized in a fashion to producemaximum productively and cost effective-ness. Omit some of the more expensivethings such as T-shirts, water bottles andtooth erasers. Give away only couponsthat can be obtained at no expense to the practice. A thorough and completeanalysis of the practice is the most essential step in determining the finalmarketing plan. When diagnosing a case,your treatment can be no better than thequality of the diagnostic records and theresearch performed in devising a treat-ment plan. Similarly, your marketing planwill be no better than the initial researchto devise that plan.

Geographic AnalysisThe type of information shown in Figure5 can be obtained from various informa-tion services such as your local chamberof commerce or a state department involved with census information. Thiswill provide valuable information on howto target the age groups.

Conclusions: The natural demographicsand economics indicate the populationwill not be growing. To increase the number of younger patients, the practiceshould provide information and education

Previous Marketing Plan

Current Patients – Children• Give away pencils with practice

name and telephone number• Water bottles with practice name

and number• Give away tooth-shaped erasers• Sugarless gum• T-shirts• Gift certificates• Video games in the office• Occasional contests• Cupcake on patient’s birthday• Skating party• Gift the day braces are removed

Current Patients – Adults• Gift the day braces are removed• Special adult day in practice

(only adults scheduled)• Christmas party

Outside Office• Visit patients in the hospital• Annual advertising in school

yearbooks• Sponsor softball team• Speaking engagements

Referring Doctors• Luncheon meetings• Golf tournament• Thanksgiving letter• Gifts at Christmas• Conferences to discuss difficult

multidisciplinary cases

Figure 4

Demographic Analysis – County Population % by AgeAge Current Year 2000 Change0-4 6.29% 5.36% down

5-9 7.01% 5.98% down

10-14 6.55% 5.82% down

15-19 6.80% 5.99% down

20-24 7.18% 6.22% down

25-29 6.82% 6.56% down

30-34 7.12% 7.41% up

35-39 7.90% 8.14% up

Figure 5

For remainder of the ‘90s, all age cells under 30 will be decreasing while the 30-40 age group will be increasing as a percentage

of the population.

Economic Analysis:According to the chamber of commerce,

there are no plans for any major business moves either in or out of the area.

continued on page 21

20

Competitive EnvironmentThere are currently 11 practicing orthodontists.

The top four competitors are listed below along with their positive and negative perceptions in the marketplace.

Competitors1. Dr. Galackowitz2. Dr. J3. Dr. Jeckell4. Dr. Livingston

Positives Negatives

Dr. GalackowitzGreat doctor Not flexible with payment plansGreat staffExcellent sterilization/high techLots of community involvementGood marketing/patient partiesNice office

Dr. JNice practice Long waits for appts., up to 20 mins.Good technically Serious/stale atmosphere, not a lot of fun

Dr. JeckellThrows things and yellsNot very friendly, rudeLots of staff turnover

Dr. LivingstonLots of staff turnoverNo consistent pricing

Figure 6

Future Marketing Plan

Estimated Cost

Adolescent PatientsBirthday cards $350Contests 160Skating party 1,200

Adult PatientsBirthday cards 100Christmas party 250Contests 160

ParentsCookies 40Carnations 80Thanksgiving treats 0Luncheon 1,500Christmas gifts 1,000

Referring DoctorsTreats – cookies, fruit, pizza, candy, apples, etc. 500

Golf outing 1,000Cruise on private boat 2,000*Birthday cards 50Appreciation luncheon 1,600

Referring StaffTreat same as above 500

Your StaffTrip to AAO 4,800*Trip to dental society meeting 2,000

Trip to district orthodontic society meeting 3,000*

Birthday lunches 360Barbeque dinner 200Appreciation dinner 360

CommunitySpecial Olympics participation 0

Christmas gifts to families 100

TOTAL $21,310*$12,000 was budgeted; therefore, asterisked items were eliminated

Figure 8

Demographic Breakdown of Dental Community

Age <35 35-44 45-54 55-64 65+ TotalGP 22 46 21 33 9 131(%) 17 35 16 25 7Ortho 2 4 3 3 1 13(%) 15 31 23 23 8

Figure 7

Marketing CalendarAdult Referring Referring

Month Adolescent Parents Patients Doctors Staffs Community Your Staff

Jan Birthday cards Birthday cards Birthday cards Birthday lunchesthroughout year throughout year throughout year all year

Feb Groundhog contest Valentine cookies Contest

Mar Easter egg contest Contest Bowling lunch

Apr Best mom contest Appreciation lunch

May Smile contest Mother’s Day Contestcarnations

Jun Olympic contest Contest Participate in# of USA gold medals Special Olympics

Jul Trivia contest Contest

Aug Trivia contest Contest Golf outing Barbeque at doctor’s house

for staff & family

Sep Back to school Attend districtskating party ortho meeting

Oct Candy corn contest Contest

Nov Christmas contest Thanksgiving Contest Thanksgiving Deliver treats Collect gifts Appreciationtreat letter for Christmas night

Dec Christmas contest Christmas party Christmas gift Collect gifts Secret Santa giftfor Christmas exchange

Figure 9

regarding the benefits of Phase 1 treat-ment. To take advantage of the increase inthe older age cells, the practice shouldcontinue to aggressively market to adultpatients, especially parents of children already in treatment.

Competitive EnvironmentEvaluationThis is one of the most interesting aspectsin the development of a good marketingplan and the third and final method of positioning your practice. Gather andcompile information on all competitivepractices. Talk to staff members, patientsand former patients, parents and dentists.Use surveys to obtain the impression orperception people have of your competi-tors’ practices. This data is then compiledas is shown in Figure 6. (The names have been changed to protect the doctors’ privacy.) In all cases, fees were compara-ble and perceived to be “high.”

Conclusions: Provide services the other

orthodontists are lacking. Address all thenegatives of the other practices and makethem your positives. In this case that involves:• Flexible payment plans.• Zero waiting time.• Fun atmosphere.• Friendly environment.• Consistent pricing; explain value of

orthodontics.Also, since age plays an important role in referral patterns (you are generally referred to by dentists within ten years ofyour own age), it is important to know thebreakdown of referring doctors by age.Figure 7 presents such a breakdown.

Conclusions: Gear the marketing plan todoctors in the 35-44 age segment. Theyhave the more mature practices and thegreatest number of child patients. Educatethem concerning Phase 1 treatment. Also market older dentists but concentrateon adult treatment and the benefits of preprosthetic orthodontics in complex

restorative cases, periodontal considera-tions, surgery and esthetics.

DevelopmentNow, and only now, a plan can be devel-oped to effectively market the practice.This is analogous to the orthodontist’s treat-ment plan. At this point, it is imperative to establish the goals and strategies to beused in your marketing plan. However, if the practice analysis has been done well, this portion is easily accomplished because the entire marketing plan, bothexternal and internal, has already been devised for you. It consists of the conclu-sions that were reached through the studyof each area of practice analysis. Your research makes it very clear exactly whatneeds to be done; now it is merely a function of prioritizing and implementingthose findings.

ImplementationNow it’s time to put all your research,

Dr. Clarkcontinued from page 19

continued on following page

analysis and planning into action. Thedoctor should already have refurbishedthe practice facility so it is attractive andclean. The staff should now be thoroughlytrained in the technical aspects of theirjob, as well as all aspects of quality cus-tomer service. Practice systems should allbe in place so everything runs smoothly.The four steps to implementing a market-ing plan are:1. Decide what you want to do 2. Determine cost3. Develop schedule4. Delegate responsibilityLet’s look at these one at a time:

DecideYou know what you’ve done in the past.What has been successful? What has not? Use a brainstorming session to record on a flip chart any idea to marketthe practice to adolescent patients andtheir parents, adult patients, referring doctors and their staff, the communityand to your own staff. Then go back and eliminate duplications and ideas that are inappropriate, impractical, complicated or expensive. Narrow downthe suggestions to specific ideas that all staff members feel good about and to which they can willingly pledge theirinvolvement. The plan requires every-one’s commitment and enthusiasm to make it work. Figure 8 provides an example.

Determine Cost (Budget)Now that you know exactly what youwould like to do, it’s time to see if it’s affordable. A budget for practice promotion must be established that will keep costs within the parameters ofthe income of the practice. Don’t justthrow money into a plan. Designate a specific amount of money you plan tospend and make the plan fit that targetamount. Look carefully at all the pro-posed marketing ideas and estimate a specific cost for each one. The costs involved in the example marketing plan we are developing are also listed in Figure 8.

Develop a ScheduleEstablish a grid (Figure 9) with the monthsof the year in the left column and the seven major groups marketed across thetop of the page. Now complete the agreed-upon marketing ideas and space themstrategically during the year to keep theflow of new patients as level as possible.Build up the weak months and keep thestrong months strong. The calendar allowsyou to space out your efforts so all market-ing energy is not expended at one or twotimes during the year. Now your calendarshould be in place and ready for the laststep in implementation.

Delegate ResponsibilityJust like major corporations, every practiceshould have a director of marketing to coordinate the marketing efforts, keep projects on schedule and hold people accountable for their marketing responsi-bilities. Analyze the entire marketingschedule and have people volunteer for the portions of the marketing plan forwhich they would like to be responsible.Everyone should share in this aspect of thepractice in order to learn to appreciate theimportance of continually building thename and reputation of the practice in thecommunity. It is everyone’s responsibility tohelp market the practice.

ConclusionThe implementation of an organized marketing plan, with the commitment ofthe doctor and total involvement of thestaff, can have a dramatic impact on thegrowth of the practice, even a mature one.A well-conceived, properly orchestratedapproach to marketing the practice will allow it to grow beyond your wildestdreams. It is not unusual for practices withwhich Orthodontic Management Grouphas worked to grow 20 to 50 percent thefirst year the plan is implemented.

As you can see, marketing does not necessarily mean advertising. Marketing a practice to increase patient flow can be done in an ethical, professional manner consistent with quality orthodontic care.As a matter of fact, advertising is the leastcost effective way to market your practice.

Mr. McMahancontinued from page 12

22

The largest dental managed care plan inAlabama is operated by BCBSA in the form of a PPO. Statewide, approximately50 percent of all practicing dentists arecontract providers for BCBSA. A review of the BCBSA directory of “PreferredDentists” reveals that participation inBCBSA’s dental PPO is not uniformthroughout the state nor is there wide-spread specialty participation except fororal surgeons.

For example, nearly 70 percent of thepracticing dentists in Birmingham are listed as contract providers, while onlytwo of 35 general dentists in Decatur areparticipants.

Orthodontists are one of the specialtygroups that have basically elected not tobecome contract providers for the BCBSAPPO. Most of the dental plans offered oradministered by BCBSA do not includeany orthodontic benefits.

The failure of most of the BCBSA plans toadequately address orthodontic coverageis epitomized in a communication to someof BCBSA’s insureds:

“Although Orthodontists and Periodontistsare listed in the directory, they are coveredonly for routine Standard Option dentalservices.

“We hope you will find that your Preferreddental benefits are convenient and easy onyour wallet.”

Well, to paraphrase Dr. Zatts, perhapsthere is a solution for orthodontists whowish to become contract providers forBCBSA. They need to shift their focusfrom traditional orthodontics to setting up “prophy parlors.” Dr. Zatts was correctin saying that dentists have options regarding managed care plans. However,only if laws like the APCL are upheld by the courts and subsequently passed either by the Congress or state legisla-tures will patients enjoy a basic right to which they should be entitled – the right to determine who will provide their dental care.

Dr. Clarkcontinued from page 21

ing patients, we are both well aware thatbiomechanics is extremely helpful in achieving predictable results. For example, I designed a reverse headgearbow to be used with a facemask to deliver force to the maxilla to achieve a predictable response. This replaces conventionally used elastics which cannotbe biomechanically applied due to lipopening. We all know that elastics withprotraction headgear often increase thevertical dimension of the face due to theextrusion of the teeth and cause themandible to swing downward and back-ward, giving us an illusion that we haveachieved forward displacement of themaxilla.

Dr. Turley: What about the “bio” in biomechanics? Do biomechanically oriented appliances give a more opti-mal biologic response for tooth move-ment than other types of appliances?

Dr. Nanda: Pat, “bio” is a big part of biomechanics. Indeed, biomechanicsteaches us to use force values which deliver tooth movement in the shortestpossible time with the least amount ofnonreversible damage to the tissues. Italso allows the use of appliances whichhave low deflection rates, are active for a long time and need small force valuesper millimeter of tooth movement.

Unfortunately, our understanding of mechanics is presently well ahead of our understanding of the biology of orthodontics. The physics of our appli-ance design is comparatively simple relative to the biological response of thetissues. But I think our knowledge of the biology of tooth movement (at the patient level) has been limited by our inability to precisely apply mechanicalprinciples to treatment.

Dr. Turley: Can biomechanics be applied to innovations by manufactur-ers for improving our appliances?

Dr. Nanda: Orthodontic manufacturersplay a major role in the field of biome-chanics from the design of brackets to the

development of new orthodontic wires. In recent years, wires such as nickel titanium and TMA® have allowed deliveryof lower and longer activating forces. In the future, I see more precalibrated orthodontic springs, wires and loopswhich will deliver predictable orthodontictooth movement.

Dr. Turley: Where is the field of bio-mechanics going in the 21st century?

Dr. Nanda: I feel market pressures willmake it imperative for all orthodontists tounderstand the wires they put into themouth. The future of biomechanics is very bright, especially in the area of orthodontic materials and development of new appliances. Even in this age ofmanaged care, HMOs and increased practice efficiencies, I am confident thespecialty will keep the quality of results always in the foreground.

Dr. Turley: Ravi, the last question, whoare/were your mentors in this field?

Dr. Nanda: I have been lucky to be associated with leaders in the field of orthodontics. My brothers, Ram andSurender, come to the forefront as mymentors. Both have contributed tremen-dously to the specialty as researchers, educators and prolific writers. In the late‘60s, I had the fortune of having Frans van der Linden as my teacher, and for a period, Allan Brodie, who was on sabbatical in Nijmegen, Holland. My last25 years have been at the University ofConnecticut, and I have had the fortune of being associated with Charlie Burstone,who is unquestionably the leader in thefield of biomechanics. Needless to say, I also have had the opportunity to be ateacher and mentor of excellent ortho-dontic graduates who are now leaders inour field in their own right.

Dr. Turley: Thank you.

Dr. Nanda: I want to thank you, Pat, andat the same time, I want to congratulateyou for your excellent contributions toour specialty.

Dr. Nandacontinued from page 5 Biomechanics in

Clinical Orthodontics

Edited by Ravindra Nanda, B.D.S., M.D.S.,Ph.D., professor and head, Department ofOrthodontics, School of Dental Medicine,University of Connecticut Health Center

Twenty-four authorities present beautifullyillustrated coverage of biomechanical prin-ciples in the first and only book to describehow these principles can be successfullyapplied to clinical orthodontics. Practicalclinical guidance includes:• A simplified approach to biomechanics

that makes its principles and their practical application easier to under-stand and employ.

• Descriptions of orthodontic treatment planning and biomechanics that help you apply specific mechanisms to specific problems.

• Advances in the use, selection and prop-erties of orthodontic wires that can improve the quality of tooth movement.

• Coverage of nonextraction treatment modalities that enables you to achieve predictable results with headgears, Herbst appliances, memory alloy springs, etc.

• Over 575 superb line drawings and clinical illustrations (100 in full color) that clarify important information and techniques.

This bookbrings togetherleading clinicians, researchers and authors in clinical orthodonticswho have made significant contributions tothe area of biomechanics. The concepts and appliance design can be applied to any technique and are easily adaptable.This addition to your library affords youthe counsel of widely recognized experts in biomechanics, presented in a format that makes it simple to understand and apply. Order information for Biomechanicsin Clinical Orthodontics is provided on page H of the Center Section.